Provider First Line Business Practice Location Address: 
170 RAILROAD ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CANAAN
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06018-2011
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
860-824-7510
    Provider Business Practice Location Address Fax Number: 
866-686-1517
    Provider Enumeration Date: 
02/27/2008